Salary Reduction Agreement For 403(B) Programs printable pdf download

Salary Reduction Agreement for 403(b) Programs

Part 1. Employee Information:

Name: _____________________________________________________________________SS#: _________________________________________________

Address: _________________________________________________________________________________________________________________________

Home Phone: ____________________________________ Date of Birth: ________________________________ Date of Hire: ______________________

Part 2. Agreement:

The above named Employee elects to become a participant of the ________________________________________ (Employer Name) 403(b) Plan and agrees to

be bound by all the terms and conditions of the plan. By executing this agreement employee authorizes the employer to reduce his or her

compensation and have that amount contributed as an elective deferral on his or her behalf into the annuity or custodial accounts as selected by the employee. It is

intended that the requirements of all applicable state or federal income tax rules and regulations (Applicable Law) will be met. The Employee understands and agrees to

the following:

this Salary Reduction Agreement is legally binding and irrevocable with respect to amounts paid or available while this agreement is

in effect;

this Salary Reduction Agreement may be terminated at any time for amounts not yet paid or available, and that a termination request

is permanent and remains in effect until a new Salary Reduction Agreement is submitted; and

this Salary Reduction Agreement may be changed with respect to amounts not yet paid or available in accordance with the

Employer's administrative procedures.

Employee is responsible for providing the necessary information at the time of initial enrollment and later if there are any changes in any

information necessary or advisable for the employer to administer the plan. Employee is responsible for determining that the salary reduction

amount does not exceed the limits set forth in applicable law and for selecting annuities or custodial accounts. Furthermore, Employee agrees to

indemnify and hold Employer harmless against any and all actions, claims and demands whatsoever that may arise from the purchase of annuities or

custodial accounts. Employee acknowledges that Employer has made no representation to Employee regarding the advisability, appropriateness or

tax consequences of the purchase of the annuity and/or custodial account described herein. Employee agrees Employer shall have no liability

whatsoever for any and all losses suffered by Employee with regard to his/her selection of the annuity and/or custodial account. Nothing herein shall

affect the terms of employment between Employer and Employee. This agreement supersedes all prior salary reduction agreements and shall

automatically terminate if Employee's employment is terminated.

Employee is responsible for setting up and signing the legal documents to establish an annuity contract or custodial account. However, in certain

group annuity contracts, the Employer is required to establish the contract.

Employee is responsible for naming a death beneficiary under annuity contracts or custodial accounts. Employee acknowledges that this is normally

done at the time the contract or account is established and reviewed periodically.

Employee is responsible for all distributions and any other transactions with vendor. All rights under contracts or accounts are enforceable solely by

Employee, Employee beneficiary or Employee's authorized representative. Employee must deal directly with the vendor to make loans, transfers,

apply for hardship distributions, begin regular distributions, or any other transactions.

Part 3. Representation by Employee for Calendar Year__________________ :

Participation in other employer plans: (you must check only one)

____ I do not and will not have any other elective deferrals, voluntary salary reduction contributions, or non-elective contributions

with any other employer.

____ I do participate in another employer's 403(b), 401(k), SIMPLE IRA/401(k), or Salary Reduction SEP. The following

information pertains to all of my other employers for the current calendar year: Includible Earnings $ ________________________ ; Elective

Deferrals $_________________; Non-elective Contributions $______________________.

I have not received a Hardship Distribution from a plan of this Employer within the last six months. I further agree to provide notification

to the employer prior to initiating a request, if I plan to elect a hardship distribution during the term of this agreement.

Maximum Elective Deferral salary reduction contribution: (you must check only one)

___ My elective deferral contribution does not exceed the Basic Limit (the lesser of my includible compensation

or $17,500).

___ My elective deferral exceeds the Basic Limit, however; I certify I am eligible for the additional Age 50 Catch-up of $5,500.

Salary Reduction Agreement For 403(B) Programs

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